In 2010, the Centers for Medicare & Medicaid Services awarded grants to states to improve health, healthcare access and healthcare quality for children enrolled in Medicaid and the Children’s Health Insurance Program using funding approved by the Children’s Health Insurance Program Reauthorization Act (CHIPRA) of 2009. Click here for more information about the national CHIPRA demonstration grant program. Click here to read a new "Spotlight on Florida" from the National Evaluation Team.
As one of the 10 grantees, Florida’s Agency for Health Care Administration joined with the Illinois Department of Healthcare and Family Services to carry out a number of demonstration projects, including the Florida Pediatric Medical Home Demonstration Project.
The overall goals of the Florida Pediatric Medical Home Demonstration Project included:
- Assess the effectiveness of systems of care
- Strengthen the ability of medical homes to provide high quality, family-centered care for all children and youth, including those with special health care needs
- Support physicians and their practice teams in applying strategies, tools and resources that improve quality of care for their patients and families
Project participants specifically worked on improvements in the following areas:
- Enhance access to care
- Provide family-centered care
- Provide and document planned, proactive, comprehensive care
- Coordinate care across all settings
"Know that your office may be good, but can be better." - Round 2 Practice Team.
Over the course of 4 years, 2 rounds of a quality improvement learning collaborative took place. Teams from the following pediatric practices across the state of Florida participated.
|A to Z Pediatrics||Mirtha Cuevas, MD Inc|
|All Children’s General Pediatrics||Orlando Health Pediatric Faculty Practice|
|Altamonte Pediatric Associates||Pediatric and Adolescent Medicine of Seminole|
|Angel Kids Pediatrics||Pediatric Associates – Miami Beach|
|Atlantic Coast Pediatrics||Pediatric Clinic, Memorial Primary Care Center|
|Bloomingdale Pediatric Associates, PA||Pediatric Partners|
|Brevard Health Alliance Monroe Center||Premier Pediatrics|
|Caladium Pediatrics||Rozalyn Hester Paschal, MD, PA|
|Children’s Health of Ocala||St Vincent’s Family Medicine Center|
|Gentle Medicine Associates||Tallahassee Pediatrics|
|Halifax Keech Health Center||The Chronic Complex Clinic at St Joseph’s|
|Jacksonville Beach Pediatric Care Center||Children’s Hospital|
|Lee Physician Group Pediatrics||The Wolff Center for Child & Adolescent Health|
|Longleaf Pediatrics, PA||UF Health Pediatrics – San Jose|
|Martin Memorial Pediatrics in St. Lucie West||USF Pediatrics|
|Martin Memorial Pediatrics in Stuart||University Pediatrics|
|Miami Children’s Hospital Pediatric Care Center||Weiss Pediatric Care|
|Wolfson Center for the Medically Complex Child at UF|
Each round of the project followed the Institute for Healthcare Improvement Breakthrough Series model and Model for Improvement. The timeline and activities for each round is shown in the figures below. Data collection over the course of the project included practice surveys and progress reports and patient record reviews. During each action period, conference calls were held between practice teams and a Quality Improvement (QI) Advisor. Patient record review data, benchmarks against project measures and best practices were presented and discussed on the calls. During in-person learning sessions, practice teams heard presentations from experts on medical home concepts, and then developed a plan for applying these concepts and approaches in their own practices.
Round 1 Project Timeline
Round 2 Project Timeline
Several additional components were offered during Round 1 and 2 of the project, including:
- Education and training for care coordinators from practice teams
Practice facilitators who worked directly with 4-5 practice teams to provide content expertise, tools for implementation and structure for quality improvement efforts
- A secure, password protected Project Workspace for practices to access their data, tools and project news, updates and information
- An email list for practices to communicate with one another about resources and strategies
Leadership and Mentorship Initiative
Performance Improvement (PI) AMA PRA Category 1 Credits™
Maintenance of Certification (MOC) Performance in Practice (Part 4) Points
Many practice teams involved parent partners in their quality improvement efforts. A Parent Partner Quality Improvement Mentor provided an orientation of the project to parent partners; provided presentations during the in-person learning sessions; facilitated monthly check in calls with parent partners; and used a parent partner email list to providing coaching, motivation and quality improvement resources. Activities parent partners worked on with their practice teams included:
- Facebook page for families with children with special health care needs
- Patients/family satisfaction surveys
- “Lunch and Learn” sessions with community organizations
- Testing the use of a patient/family suggestion box in the practice waiting area
- Development of family advisory council
- Practice team quality improvement meetings, including practice facilitation site visits
Practice teams worked on improving 2 main parts of care: 1) following evidence-based, clinical care guidelines and processes, and 2) putting formal structures in place to provide the highest quality of care possible. The improvements made by practice teams in these 2 areas shows the success of the project’s collaborative approach.
Evidence-based Guidelines and Processes
The most significant gains were seen in the following areas listed below. For a complete list of combined data results from Round 1, click here and from Round 2, click here .
- Identification of a primary care pediatrician or physician-led care team for all patients
- Current medical summary or comprehensive care plan reviewed and offered to patients during their most recent visit
- Documentation of 1 completed standardized developmental screen at patients’ 24 month health supervision visit
- Asthma control assessment given to patients diagnosed with asthma during their most recent visit
- Current written asthma action plan reviewed and offered to patients diagnosed with asthma during their most recent visit
The most significant gains were seen in the following areas listed below.
- Use of a registry or system of accessible and clinically useful information for a patient population to:
- Identify or proactively remind clinicians and patients/families of needed services
- Track referrals, protocols and recommended actions
- Identify patient need for care coordination services
- A vision for medical home improvement that is shared with the entire practice
- Schedule of regular team meetings to reflect on lessons learned from changes put in place, to problem solve and to plan for future improvements
- Tracking Plan, Do, Study, Act cycles over time
- Applying the results of successful improvements practice-wide
- Sharing feedback from families with the entire practice
- Use of reliable ways to communicate with specialists and other providers outside the medical home for patients whose care is co-managed
- Asking about special needs and accommodations of the patient when scheduling office visits and planning accordingly
The tremendous efforts and dedication of the practice teams over the course of the project led to many valuable lessons learned that may be applicable to future learning collaboratives/quality improvement projects. These lessons are summarized below.
Initiating and sustaining significant changes in practice was a challenge experienced by all teams sometimes because of resistance to change and strained communication among staff. The most consistent advice for other practices that are considering adopting the medical home model was to identify at least one physician champion who can maintain motivation and momentum throughout the process
"...most of us are not aware of the fact that the family-centric approach goes a long way to provide better care for patients… the majority of pediatric offices do not have to employ additional personnel and still effectively implement the core features of the medical home model. Only thing that is absolutely required is dedicated leadership and total buy-in from office personnel.” - Round 2 practice team
Working with parent partners on quality improvement initiatives is rewarding, yet challenging. Parent partners need clarity about their role and training on quality improvement concepts. They need this early on in their involvement. Also, practices need guidance on how to effectively engage a parent partner.
Learning from, and networking with, peers was incredibly valuable and helpful. Practices especially valued the peer-to-peer learning and networking opportunities that took place during in-person learning sessions and monthly conference calls/webinars. Hearing from other practice teams also served as a motivator throughout the medical home change process.
Change occurs in the context of a busy, dynamic practice environment. The attention put towards working on quality improvement efforts competed for practice teams’ attention at times due to staff turnover, rollout of Medicaid managed care, back-to-school season and using a new electronic medical record (EMR) system. It takes time for the impact of changes to practice-based systems and processes to be seen.
Personalized support, guidance and coaching provided by practice facilitators was extremely successful and one of the most valued aspects of the project by teams. Facilitation visits created opportunities for all staff, clinicians and parent partners to reflect as a group on their current successes and challenges, identify priorities, discuss ideas for future changes and use practice-level data to help inform these changes. Facilitation and coaching encourages all staff and parent partners to see themselves as valued members of the practice team.
Benefits of Participation
The importance of offering real benefits and incentives to participants in quality improvement initiatives such as the project described here cannot be understated. Benefits like stipends, scholarships, American Board of Pediatrics Maintenance of Certification points and/or AMA PRA Category 1 Credits™ provide participants motivation and recognition of their efforts.
Health Information Technology
Several practice teams put a new EMR into place during the project. The EMR made a big difference in tracking and documentation, use of templates and use of prompts/reminders. EMR implementation had the greatest impact on care planning, use of risk assessments, chronic condition management and developmental screening. Although the EMRs were beneficial after implemented, they oftentimes reduced the amount of time practice teams had to work on project activities. In addition, several practices had trouble gaining meaningful data from their EMR and making changes to their EMR to make it more appropriate for pediatric care.
Sponsored by the Florida Pediatric Medical Home Demonstration Project, a Blueprint for Success: The Pediatric Medical Home is Here to Stay conference was held on Friday, February 6th in Orlando, FL. The conference was a huge success with approximately 130 attendees including physicians, allied health providers and health care administrators. Experts presented on such topics as behavioral health integration into primary care, use of EMRs and registries, chronic disease management, Florida’s transition to Medicaid managed care and child health financing.
This project was made possible by a federal grant authorized by the Children’s Health Insurance Program Reauthorization Act (CHIPRA) under Section 401(d) to enhance medical homes for children, particularly those with special health care needs, enrolled in the Medicaid, Medicaid health plan or KidCare programs. The grant program was administered by the Centers for Medicare & Medicaid Services (CMS). The project was developed and facilitated by:
- American Academy of Pediatrics
- The Family Café
- The Family Network on Disabilities
- Florida Agency for Health Care Administration
- Florida Chapter of the American Academy of Pediatrics
- Florida Children’s Medical Services Network
- Health Management Associates
- University of Florida Institute for Child Health Policy (ICHP)
- University of South Florida College of Medicine
Click here for more information about Quality Improvement (QI) at the AAP, including how to participate in QI initiatives. You can also visit the AAP’s website for information about its Maintenance of Certification Portfolio Program. For more information about the Florida Pediatric Medical Home Demonstration Project, contact Christina Boothby, Manager, Medical Home Initiatives.